Bi-directional fixating/locking transvertebral body screw/intervertebral cage stand-alone constructs

ABSTRACT

A bi-directional fixating transvertebral (BDFT) screw/cage apparatus is provided. The BDFT apparatus includes an intervertebral cage including a plurality of internal angled screw guides, a plurality of screw members, and a novel screw locking mechanism which consists of leaf springs which mechanically interact with BDFT screws which have ratcheted screw heads. The small leaf springs allow the ratchet teeth of the screw heads to rotate only in the penetrating direction. Due to the geometric orientation of the ratchet teeth vis-a-vis the adjacent spring leaf, rotation of the screw head in the opposite direction is prevented by the insertion of the string leaf in the space between the ratchet teeth (trough) of its final rotation. The uni-rotational interaction between the screw head-ratchet teeth/troughs and adjacent leaf spring is the mechanical basis for this novel locking mechanism. The internal angled screw guides orient a first screw member superiorly and a second screw member inferiorly in some embodiments, and orient a second screw member and a third screw member superiorly, and a first screw member and fourth screw member inferiorly in other embodiments. The intervertebral cage is adapted for posterior lumbar intervertebral placement, anterior lumbar intervertebral placement, anterio-lateral thoracic intervertebral placement, or anterior cervical intervertebral placement.

This application is a Continuation-In-Part Application, for whichpriority is claimed under 35 U.S.C. § 120, of copending U.S. patentapplication Ser. No. 13/103,994, filed on May 9, 2011 (Attorney DocketNo. 3003/0107PUS8), which is a Divisional of U.S. patent applicationSer. No. 12/054,335, filed on Mar. 24, 2008 (now U.S. Pat. No. 7,972,363B2, issued on Jul. 5, 2011) (Attorney Docket No. 3003/0107PUS1), whichis a Continuation-In-Part of copending application Ser. No. 11/842,855,filed on Aug. 21, 2007 (now U.S. Pat. No. 7,942,903, issued May 17,2011) (Attorney Docket No. 3003/0105PUS1), which is aContinuation-In-Part of application Ser. No. 11/536,815, filed on Sep.29, 2006 (now U.S. Pat. No. 7,846,188 B2, issued Dec. 7, 2010) (AttorneyDocket No. 3003/0104PUS2), which is a Continuation-In-Part ofapplication Ser. No. 11/208,644, filed on Aug. 23, 2005 (now U.S. Pat.No. 7,704,279 issued on Apr. 27, 2010) (Attorney Docket No.3003/0104PUS1), the entire contents of all of the above identifiedpatent applications are hereby incorporated by reference in theirentirety and for which priority of each of the above-identifiedapplications is claimed under 35 U.S.C. § 120.

This application also is a Continuation-In-Part Application, for whichpriority is claimed under 35 U.S.C. § 120, of copending application Ser.No. 13/084,543, filed on Apr. 11, 2011 (Attorney Docket No.3003/0105PUS2), which is a Divisional of copending application Ser. No.11/842,855, filed on Aug. 21, 2007 (now U.S. Pat. No. 7,942,903, issuedMay 17, 2011) (Attorney Docket No. 3003/0105PUS1), which is aContinuation-In-Part of application Ser. No. 11/536,815, filed on Sep.29, 2006 (now U.S. Pat. No. 7,846,188 B2, issued Dec. 7, 2010) (AttorneyDocket No. 3003/0104PUS2), which is a Continuation-In-Part ofapplication Ser. No. 11/208,644, filed on Aug. 23, 2005 (now U.S. Pat.No. 7,704,279 issued on Apr. 27, 2010) (Attorney Docket No.3003/0104PUS1), the entire contents of all of the above identifiedpatent applications are hereby incorporated by reference in theirentirety and for which priority of each of the above-identifiedapplications is claimed under 35 U.S.C. § 120.

This application also is a Continuation-In-Part Application, for whichpriority is claimed under 35 U.S.C. § 120, of copending application Ser.No. 13/401,829, filed on Feb. 21, 2012 (Attorney Docket No.3003/0107PUS5), which claims priority under 35 U.S.C. § 119(e) of U.S.Provisional Application No. 61/445,034, filed on Feb. 21, 2011 (AttorneyDocket No. 3003/0107PR05), the entire contents of all of the aboveidentified patent applications are hereby incorporated by reference intheir entirety.

This application also claims priority under 35 U.S.C. § 119(e) of U.S.Provisional Application No. 61/451,582, filed on Mar. 10, 2011 (AttorneyDocket No. 3003/0107PR07), U.S. Provisional Application No. 61/451,579,filed on Mar. 10, 2011 (Attorney Docket No. 3003/0107PR06), and U.S.Provisional Application No. 61/445,034, filed on Feb. 21, 2011 (AttorneyDocket No. 3003/0107PR05), the entire contents of all of the aboveidentified patent applications are hereby incorporated by reference intheir entirety.

U.S. patent application Ser. Nos. 13/084,543, filed on Apr. 11, 2011(Attorney Docket No. 3003/0105PUS2), Ser. No. 11/842,855, filed on Aug.21, 2007 (Attorney Docket No. 3003/0105PUS1), Ser. No. 11/536,815, filedon Sep. 29, 2006 (Attorney Docket No. 3003/0104PUS2), and Ser. No.11/208,644, filed on Aug. 23, 2005 (Attorney Docket No. 3003/0104PUS1),each claim the benefit of priority under 35 U.S.C. § 119(e) of U.S.Provisional Application No. 60/670,231, filed on Apr. 12, 2005 (AttorneyDocket No. 3003/0102PR01), and this application hereby incorporates theclaim of priority to this provisional application under 35 U.S.C. §119(e) from the aforementioned intermediate applications (for whichpriority of each intermediate application is claimed under 35 U.S.C. §120); and the entire contents of all of the above identified patentapplications are hereby incorporated by reference in their entirety.

FIELD OF DISCLOSURE

The present invention relates to a unique universal bi-directional screw(BDS) system, and in particular its application to the spine, alsoreferred to as bi-directional fixating transvertebral (BDFT) screw/cageconstructs which can be used as stand-alone intervertebral devices whichcombine the dual functions of an intervertebral spacer that can befilled with bone fusion material(s), as well as a bi-directionaltransvertebral bone fixating/fusion screw apparatus. In the posteriorlumbosacral and thoracic spine, intervertebral cage/BDFT screwconstructs can be used as stand-alone devices obviating the need forpedicle screw fixation in many but not all cases. In the anteriorcervical, thoracic and lumbosacral spine, intervertebral cage/BDFT screwconstructs can be used as stand-alone devices obviating the need foranterior or lateral (thoracic and lumbosacral) spinal plating, and/orsupplemental posterior pedicle screw fixation.

BACKGROUND

The history and evolution of instrumented spinal fusion in the entirehuman spine has been reviewed in related applications Ser. No.12/054,335, filed on Mar. 24, 2008, Ser. No. 13/084,543, filed on Apr.11, 2011, Ser. No. 11/842,855, filed on Aug. 21, 2007, Ser. No.11/536,815, filed on Sep. 29, 2006, and Ser. No. 11/208,644, filed onAug. 23, 2005, the contents of which are hereby incorporated byreference in their entirety. Conventionally, the majority of posteriorcervical and almost all posterior thoracic and lumbosacral fusionsurgical techniques are typically supplemented with pedicle screwplacement. Conventionally, the majority of anterior cervical spinalfusions, and many anterio-lateral thoracic, and anterior oranterio-lateral lumbosacral fusions are supplemented with anterior oranterior-lateral spinal plating, and very often, in particular in thethoracic and lumbosacral spine, are supplemented with posterior pediclescrew instrumentation.

Complications of pedicle screw placement in cervical, thoracic andlumbosacral spine include duration of procedure, significant tissuedissection and muscle retraction, misplaced screws with neural and/orvascular injury, excessive blood loss, need for transfusions, prolongedrecovery, incomplete return to work, and excessive rigidity leading toadjacent segmental disease requiring further fusions and re-operations.Recent advances in pedicle screw fixation including minimally invasive,and stereotactic CT image-guided technology, and the development offlexible rods, imperfectly address some but not all of these issues.

Complications of anterior plating in the cervical spine includepotential plate, and/or screw esophageal compression, and misplacedscrews leading to neurovascular injury. Complications of anterior oranterior-lateral plating in the anterior lumbar spine include potentialdevastating injury to the major vessels due to chronic vascular erosionof the major vessels, or acute vascular injuries due to partial orcomplete plate and/or screw back out. Furthermore, for re-do surgeries,plate removal can be arduous, with potential complications of prolongedesophageal retraction, vascular injury and screw breakage. Recentadvances including diminishing the plate width and/or profile, andabsorbable plates, imperfectly address some but not all of these issues.

Complications of all conventional spinal anterior intervertebral deviceconstructs are their potential for extrusion in the absence of plating.Hence, they are supplemented with anterior plating to prevent extrusion.Complications of posterior lumbosacral intervertebral device constructin the presence or absence of supplemental pedicle screw fixation isdevice extrusion, and potential nerve root and/or vascular injuries.

SUMMARY

Herein described are multiple exemplary embodiments of a device whichcombines in a single stand-alone construct the dual functions of: a) anintervertebral cage spacer which can be filled with bone fusion materialmaintaining disc height, and, b) a bi-directional fixating/fusiontransvertebral body screw apparatus. These embodiments are described forposterior and anterior lumbar (and anterio-lateral thoracic)intervertebral placement, and anterior cervical intervertebralplacement. The present invention recognizes the aforementioned problemswith prior art apparatus and solves these problems by, among otherthings, improving upon the designs illustrated in the aforementionedrelated applications. The present application provides an advanced andnovel bi-directional fixating transvertebral (BDFT) screw/cage apparatuswith a modified novel cage which has indentations on the upper aspect ofthe screw box adjacent to the internalized angled screw guides. Theseindentations have leaf springs which are press fit into theseindentations. The leaf springs function as screw locking mechanisms inconjunction with specialized BDFT screws that are designed withratcheted screw heads. The small leaf springs which are perpendicularlyaligned with the screw head ratchet spiked teeth and troughs allow theratchet teeth of the screw heads to rotate only in the penetratingdirection. Due to the geometric orientation of the ratchet teeth andtroughs vis-à-vis the spring leaf, rotation of the screw head in theopposite direction is prevented. The spring leaf engages the spacebetween the ratchet teeth (troughs) upon its final allowed turn, andprevents any rotation in the opposite direction thereby locking thescrew into its final position. The interaction between the adjacent leafsprings and the screws ratcheted teeth and troughs which only allowscrew rotation in the penetrating direction is the mechanical basis forthis novel locking mechanism. This mechanism can be used not only forthese constructs but also with any other device which requires a lockingscrew. All these novel modifications improve the probability of a solidfusion with this new invention.

The exemplary embodiments of a bi-directional fixating transvertebral(BDFT) screw/cage apparatus provide as strong or stronger segmentalfusion as pedicle screws without the complications arising from pediclescrew placement, which include misplacement with potential nerve and/orvascular injury, violation of healthy facets, possible pedicledestruction, blood loss, and overly rigid fusions. By placing screwsacross the intervertebral space from vertebral body to vertebral body,engaging anterior and middle spinal columns and not the vertebral bodiesvia the transpedicular route thereby excluding the posterior spinalcolumn, then healthy facet joints, if they exist, are preserved. Becausethe present invention accomplishes both anterior and middle columnfusion, without rigidly fixating the posterior column, the presentinvention in essence creates a flexible fusion.

The present invention recognizes that the very advantage oftranspedicular screws which facilitate a strong solid fusion by rigidlyengaging all three spinal columns is the same mechanical mechanismwhereby complete inflexibility of all columns is incurred therebyleading to increasing rostral and caudal segmental stress which leads toan increased rate of re-operation.

Transvertebral fusion also leads to far less muscle retraction, bloodloss and significant reduction in operating room (O.R.) time. Thus, thecomplication of pedicle screw pull out, and hence, high re-operationrate associated with the current embodiment of flexible fusion pediclescrews/rods is obviated. The lumbosacral intervertebral cage/BDFT screwconstructs can be introduced via posterior, lateral, transforaminal oranterior interbody fusion approaches/surgical techniques. Although onecan opt to supplement these constructs with transpedicular screws therewould be no absolute need for supplemental pedicle screw fixation withthese operative techniques.

The anterior placement of a bi-directional fixating transvertebral(BDFT) screw/cage apparatus according to the embodiments of the presentinvention into the cervical and lumbar spine obviates the need forsupplemental anterior cervical or anterior lumbar plating. The solepurpose of these plates is to prevent intervertebral device extrusion.This function is completely obviated and replaced by the dualfunctioning bi-directional fixating transvertebral (BDFT) screw/cageapparatus, according to the present invention. The obvious advantage ofthis is a significant savings in operative time, and prevention ofinjuries associated with plating, in particular esophageal, large andsmall vessel injuries, and spinal cord nerve root injuries.

Because the embodiments of the bi-directional fixating transvertebral(BDFT) screw/cage apparatus engage a small percentage of the rostral andcaudal vertebral body surface area, multi-level fusions can be performedwith these devices.

Conventionally, failed anterior lumbar arthroplasties are salvaged bycombined anterior and posterior fusions. Intervertebral cage/BDFT screwconstructs may be utilized as a one-step salvage mechanism forfailed/extruded anteriorly placed lumbar artificial discs obviating theneed for supplemental posterior pedicle screws and/or anterior lumbarplating thereby significantly reducing and/or eliminating co-morbiditiesassociated with these other salvage procedures.

Likewise, anterior cervical intervertebral cage/BDFT screw constructplacement can be used to salvage failed anterior cervicalarthroplasties, and re-do fusions without having to supplement withcervical anterior plates, thereby reducing the morbidity of thisprocedure.

In addition, if a patient develops a discogenic problem necessitatinganterior cervical discectomy and fusion at a level above or below apreviously fused and plated segment, the present invention reduces oreliminates the need to remove the prior plate in order to place a newsuperior plate, because the function of the plate is replaced by thedual functioning intervertebral cervical construct, thereby reducing theoperating room time and surgical morbidity of this procedure.

Furthermore, because of the orientation and length of the BDFT screwswithin the intervertebral cage/BDFT constructs, multiple level fusionscan be easily performed.

For example, an exemplary embodiment is directed to an intervertebralcage spacer and bi-directional fixating/fusion transvertebral bodyscrew/cage apparatus. The apparatus includes an intervertebral cage formaintaining disc height. The intervertebral cage includes a firstinternal screw guide and a second internal screw guide adjacent to novelcage indentations which contains a press-fit leaf spring. The apparatusfurther includes a first screw member having a screw head with ratchetteeth, a tapered end and a threaded body disposed within theintervertebral cage, a second screw member having a screw head withratchet teeth, a tapered end and a threaded body disposed within theintervertebral cage, and a first screw locking mechanism that preventsthe first screw member and the second screw from pulling-out of thefirst internal screw guide and the second internal screw guide.

Another exemplary embodiment is directed to an integral intervertebralcage spacer and bi-directional fixating/fusion transvertebral body screwapparatus, including an intervertebral cage having a plurality ofinternal angled screw guides. The apparatus further includes a pluralityof screw members having a screw head with ratchet teeth and troughs, atapered end and a threaded body disposed within the plurality ofinternal angled screw guides of the intervertebral cage, which areadjacent to novel cage indentations which contain press fit leafsprings. Due to the geometric orientation of the ratchet teeth on thescrew head, the adjacent leaf springs allow the screws to rotate only inthe penetrating direction. Screw rotation in the opposite, back out,direction is prevented because the leaf spring engages the space inbetween the ratchet teeth (troughs) preventing this opposite rotationand hence locking it preventing the plurality of screw members frompulling out of the plurality of internal angled screw guides.

Another exemplary embodiment is directed to a method of inserting abi-directional fixating transvertebral (BDFT) screw/cage apparatusbetween a first vertebral body and a second vertebral body. The methodincludes measuring a dimension of a disc space between the firstvertebral body and the second vertebral body, determining that the discspace is a posterior or lateral lumbar disc space, an anterior lumbardisc space, or an anterior cervical disc space, selecting anintervertebral cage based on the measured dimension of the disc spaceand based on the determination of the disc space being the posteriorlumbar disc space, the lateral lumbar disc space, the anterior lumbardisc space, or the anterior cervical disc space, inserting the selectedintervertebral cage into a midline of the disc space until the selectedintervertebral cage is flush or countersunk relative to the firstvertebral body and the second vertebral body, inserting a first screwmember into a first internal screw guide of the selected intervertebralcage, inserting a second screw member into a second internal screw guideof the selected intervertebral cage, screwing the first screw member andthe second screw member into the first vertebral body and the secondvertebral body respectively, confirming a position and placement of theintervertebral cage relative to the first vertebral body and the secondvertebral body, and locking the first screw member and the second screwmember in a final position by its final turn when it's flush with thesurface of the cage. The leaf spring prevents screw back out or pull outby engaging and locking the space between the ratchet teeth (troughs) ofthe screw head when the screws are in their final resting positions.

The posterior lumbar BDFT cage screw apparatus is uniquely designed inorder to get into the posterior space and obtain proper screwangulations. Two exemplary embodiments are described; one that isrectangular and one that is elliptical and concave mimicking theposterior intervertebral disc space. In both exemplary embodiments, theaxes of the internal screw guides are not horizontally aligned as theyare in the cervical embodiment. Their axes must be oblique one to theother, and the screw guides must be very close to one another, in orderfor the screws to achieve proper vertebral body penetration in such arestricted posterior lumbar inter space.

In the embodiments having an anterior lumbar embodiment four screwdesign, in order to achieve maximal stability and to prevent subsidence,the lateral two screws penetrate the inferior vertebral body, and themiddle two screws project to the superior vertebral body.

In all BDFT embodiments, the screw angle guides have an approximatetwenty five degree angle. The angles can be variable or divergent.

In all embodiments the screw drill guide narrows such that the screwhead is countersunk into the cage and thus it can be locked even in theabsence of an additional screw locking mechanism. The screw lockingmechanism described herein is yet an additional mechanism preventingscrew back out.

BRIEF DESCRIPTION OF THE DRAWINGS

The accompanying drawings are presented to aid in the description ofembodiments of the invention and are provided solely for illustration ofthe embodiments and not limitation thereof.

FIG. 1A illustrates a top view of an anterior cervical intervertebralcage/BDFT screw construct according to an embodiment of the invention.

FIG. 1B illustrates a bottom perspective (isometric) view of an anteriorcervical intervertebral cage/BDFT screw construct according to anembodiment of the invention.

FIG. 1C illustrates a side view of an anterior cervical intervertebralcage/BDFT screw construct according to an embodiment of the invention.

FIG. 1D illustrates a bottom, perspective view of an anterior cervicalintervertebral cage/BDFT screw construct according to an embodiment ofthe invention.

FIG. 1E illustrates a front, perspective, exploded view of an anteriorcervical intervertebral cage/BDFT screw construct according to anembodiment of the invention.

FIG. 1F illustrates a top, perspective exploded view of an anteriorcervical intervertebral cage/BDFT screw construct according to anembodiment of the invention.

FIG. 1G illustrates a top, perspective exploded view of an anteriorcervical intervertebral cage/BDFT screw construct with visualizedinternalized angled screw guides according to an embodiment of theinvention.

FIG. 2A illustrates a top view of an anterior lumbar intervertebralcage/BDFT screw construct according to an embodiment of the invention.

FIG. 2B illustrates a bottom view of an anterior lumbar intervertebralcage/BDFT screw construct according to an embodiment of the invention.

FIG. 2C illustrates a top, perspective view of an anterior lumbarintervertebral cage/BDFT screw construct according to an embodiment ofthe invention.

FIG. 2D illustrates a side, perspective view of an anterior lumbarintervertebral cage/BDFT screw construct according to an embodiment ofthe invention.

FIG. 2E illustrates a top, perspective view of an anterior lumbarintervertebral cage/BDFT screw construct according to an embodiment ofthe invention.

FIG. 2F illustrates a top exploded view of an anterior lumbarintervertebral cage/BDFT screw construct according to an embodiment ofthe invention.

FIG. 2G illustrates a top, perspective exploded view of an anteriorlumbar intervertebral cage/BDFT screw construct according to anembodiment of the invention.

FIG. 3A illustrates a top view of a posterior lumbar rectangularlydesigned intervertebral cage/BDFT construct according to an embodimentof the invention.

FIG. 3B illustrates a front, perspective view of a posterior lumbarrectangularly designed intervertebral cage/BDFT construct according toan embodiment of the invention.

FIG. 3C illustrates a side, perspective view of a posterior lumbarrectangularly designed intervertebral cage/BDFT construct according toan embodiment of the invention.

FIG. 3D illustrates a front, perspective view of a posterior lumbarrectangularly designed intervertebral cage/BDFT construct according toan embodiment of the invention.

FIG. 3E illustrates a top, perspective exploded view of a posteriorlumbar rectangularly designed intervertebral cage/BDFT constructaccording to an embodiment of the invention.

FIG. 3F illustrates a top, perspective exploded view of a posteriorlumbar rectangularly designed intervertebral cage/BDFT constructaccording to an embodiment of the invention.

FIG. 4A illustrates a top view of a posterior lumbar ellipticallydesigned intervertebral cage/BDFT construct according to an embodimentof the invention.

FIG. 4B illustrates a front, perspective view of a posterior lumbarelliptically designed intervertebral cage/BDFT construct according to anembodiment of the invention.

FIG. 4C illustrates a side view of a posterior lumbar ellipticallydesigned intervertebral cage/BDFT construct according to an embodimentof the invention.

FIG. 4D illustrates a front, perspective view of a posterior lumbarelliptically designed intervertebral cage/BDFT construct according to anembodiment of the invention.

FIG. 4E illustrates a top, perspective exploded view of a posteriorlumbar elliptically designed intervertebral cage/BDFT constructaccording to an embodiment of the invention.

FIG. 4F illustrates a top, perspective exploded view of a posteriorlumbar elliptically designed intervertebral cage/BDFT constructaccording to an embodiment of the invention.

FIG. 5A illustrates a perspective view of an intervertebral cageconstruct according to an embodiment of the invention.

FIG. 5B illustrates another perspective view of an intervertebral cageconstruct according to an embodiment of the invention.

FIGS. 5C(i) and 5C(ii) illustrate top, perspective view of anintervertebral cage construct according to an embodiment of theinvention.

FIG. 5D illustrates a top, perspective, exploded view of a positioningtool/screw guide/box expander.

FIG. 5E illustrates a superior oblique perspective view of thepositioning tool/drill guide/box expander component.

DETAILED DESCRIPTION OF THE EXEMPLARY EMBODIMENTS

Aspects of the invention are disclosed in the following description andrelated drawings directed to specific embodiments of the invention.Alternate embodiments may be devised without departing from the scope ofthe invention. Additionally, well-known elements of the invention willnot be described in detail or will be omitted so as not to obscure therelevant details of the invention.

The word “exemplary” is used herein to mean “serving as an example,instance, or illustration.” Any embodiment described herein as“exemplary” is not necessarily to be construed as preferred oradvantageous over other embodiments. Likewise, the term “embodiments ofthe invention” does not require that all embodiments of the inventioninclude the discussed feature, advantage or mode of operation.

With reference to FIGS. 1A-5E, exemplary embodiments of the inventionwill now be described.

1. Exemplary Medical Device

Referring to FIGS. 1A-5E the above described problems of theconventional art can be solved in the cervical, thoracic and lumbosacralspines by insertion into the denuded intervertebral disc space multipleembodiments of a bi-directional fixating transvertebral (BDFT)screw/cage apparatus.

For example, FIGS. 1A-1G illustrate three-dimensional views of anexemplary embodiment of an anterior cervical intervertebral cage/BDFTconstruct 10. In this embodiment, the top portion of the cage 10 hasindentations 70 that are adjacent to the internalized screw guides 80,90 (FIG. 1F) which contain press-fit leaf spring screw lockingmechanisms 20. The cage 10 also includes additional indentations 12 onthe side surfaces of the cage 10 for insertion of the prongs of aninsertion device. In an exemplary embodiment, a side surface of the cage10 can elliptically contoured when viewed from the side (FIG. 1C) to fitinto the bi-concave cervical disc space. The embodiment includes twoscrews 30, 40. The screws 30, 40 include screw heads with ratchet teeth.The teeth have troughs in between. A first screw 30 is orientedrostrally (superiorly) and a second screw 40 is oriented caudally(inferiorly). The cage 10 can include a cavity 60 for bone productplacement. The cage 10 includes two built in internalized screw/drillguides 80, 90 (e.g., approximately having a 25 degree angulation), onefor each screw 30, 40, which orient the screws 30, 40 bi-directionallyin opposite directions. The cage 10 can include a screw guide tunnelexit 13 adjacent to the bone cavity 60 (FIG. 1). One of ordinary skillin the art will recognize that the internalized screw/drill guides 80,90 can have different degrees of angulation and/or different positionswithin the cage 10.

In an embodiment, the cage includes at least one screw guide 80 or 82having a predetermined trajectory (e.g., preferably having a 25 degreeangulation) that may make placement of all screws equally facile, moreamenable to multi-level placement, and may diminish the need forexternal drill guides. In other embodiments, the cage includes at leasttwo screw guides 80, 82 having a predetermined trajectory (e.g.,preferably having a 25 degree angulation) that may make placement of allscrews equally facile, more amenable to multi-level placement, and maydiminish the need for external drill guides. In other embodiments, thecage can include a screw guide 80, 82 having another predeterminedtrajectory, such as an angulation of substantially 25 degrees (e.g., anangulation ranging from 20 degrees to 30 degrees). In other embodiments,the cage can include a screw guide 80, 82 having another predeterminedtrajectory, such as an angulation ranging from 20 degrees to 25 degrees,an angulation ranging from 25 degrees to 30 degrees, an angulationranging from 25 degrees to 35 degrees, an angulation ranging from 25degrees to 35 degrees, an angulation ranging from 20 degrees to 40degrees, an angulation ranging from 25 degrees to 40 degrees, etc. Theembodiments of the cage can include one or more screw/drill guides 80,82 having different angles and/or different positions within the cage.

The built in tunnels of the screw guides 80, 90 provide an importantadvantage of ensuring that only one prescribed angled trajectory ispossible for transvertebral screw placement. The built in tunnels narrowgoing downward. This facilitates the locking of the screw head to thetop of the cage 10 even in the absence of the locking mechanismdescribed herein. Embodiments of the intervertebral cages 10 can bedesigned with internalized screw/drill guides 80, 90 with differentangles and/or different positions within the cage 10. The angle and sizeof the screws 30, 40 make them amenable to single or multi-levelplacement. The superior and inferior surfaces or edges of the lumbarcage 10 can include ridges 50 or the like to facilitate integration andfusion with superior and inferior vertebral bodies.

The embodiment can include a leaf spring 20 which can be, for example,press-fit into the indentation 70 adjacent to the self-drilling internalscrew guides, 80, 90 on top of the cage 10. The leaf spring 20 can bemanufactured from a variety of materials, such as titanium. When thescrews 30, 40 with ratcheted screw heads are turned, the first screwmember 30 and the second screw member 40 are locked in a final positionby its final turn when the screw head is flush with the surface of thecage 10. The adjacent leaf spring 20 prevents screw back out or pull outby engaging and locking the space between the ratchet teeth (trough) ofthe screw head when the screws 30, 40 are in their final restingpositions. This engagement prevents any rotation of the screw 30, 40 inthe opposite direction.

The exemplary embodiments of the locking mechanism are an evolutionaryadvance and improvement compared to the apparatus illustrated in theaforementioned related applications. The novel embodiments are quiteunique and different from all other conventional screw lockingmechanisms.

FIGS. 2A-2G illustrate three-dimensional views of an exemplaryembodiment of an anterior lumbar intervertebral cage/BDFT construct. Inthis embodiment, the cage 110 includes indentations 194 on top of thecage 10 laterally adjacent to all four internalized screw guides 190,192 (FIG. 2G), which contain press-fit leaf springs 120. The cage 110also can include indentations 12 on both side surfaces for insertion ofprongs of an implantation tool. This cage 110 can be larger than thecervical cage 10 and also can include elliptically contoured sidewallswhen view from the side to fit into the bi-concave lumbar disc space(FIG. 2D). The cage 110 includes four (4) horizontally alignedinternalized screw guides 190, 192 for four (4) screws 130, 140, 150,160. The two lateral (left and right) screws 130, 160 are orientedinferiorly, and the two middle screws 140, 150 are oriented superiorly.The axes of these guides 190, 192 and screws 130, 140, 150, 160 are notperfectly horizontal with respect to each other. Each lateral screwguide/screw is obliquely oriented with respect to its adjacent medialscrew guide/screw. This is necessary to achieve the proper trajectoryfor bone penetration along with the precise angle of the screw guides.The screw guide tunnel exits 13 are illustrated in FIG. 2C and are incontinuity (connected) with the enlarged bone cavity 180. In theembodiment, the orientations of the four screw guides 190, 192 (andscrews; 130, 140, 150, 160) are selected because of their symmetry andinherent stability.

The cage 110 can include a large cavity 180 for bone product placement.The cage 110 includes four built-in internalized screw/drill guides 190,192 (e.g., having an approximate 25 degree angulation), one for eachscrew 130, 140, 150, 160. Other embodiments of the intervertebral cage110 can be designed with internalized screw/drill guides 190, 192 withdifferent angles and/or different positions within the cage 110. Theangle and size of the screws 130, 140, 150, 160 make them amenable tosingle or multi-level placement. The superior and inferior surfaces oredges of the cage 110 can include ridges 170 or the like to facilitateintegration and fusion with superior and inferior vertebral bodies. Inan embodiment, there are no compartmental divisions in the cavity 180for bone product placement to maximize the quantity of bone for fusion.

The cage 110 includes four leaf springs 120 that can be, for example,press-fit to the indentations 194 adjacent to the internalized screwguides 190, 192 on top of the cage 110 (FIG. 2). In the embodiment, thecage 110 includes one leaf spring locking mechanism 120 per screw 130,140, 150, 160. However, in other embodiments, one locking mechanism 120can be provided for each screw 130, 140, 150, 160, or one lockingmechanism 120 can be provided for two or more screws 130, 140, 150, 160.The top of the cage 110 includes an indentation 194 for each leaf springlocking mechanism 120. Each leaf spring locking mechanism 120 also canbe designed to rest and be press-fit into the indentations 194, whichare adjacent to the in-built self drilling screw guides 190, 192. Theleaf spring locking mechanism 120 can be manufactured from a variety ofmaterials, such as titanium.

When each of the screws 130, 140, 150, 160 with ratcheted screw headsare turned, the screws 130, 140, 150, 160 are locked in a final positionby its final turn when the screw head is flush with the surface of thecage 110. The adjacent leaf spring 120 prevents screw back out or pullout by engaging and locking the space between the ratchet teeth of thescrew head (trough) when the screws 130, 140, 150, 160 are in theirfinal resting positions. This engagement prevents any rotation of thescrew 130, 140, 150, 160 in the opposite direction. It should also benoted that because of the narrowing of the screw guide tunnel 190, 192,when the screw head is countersunk into the top of the cage 110, thisalso serves as a preliminary locking mechanism.

The exemplary embodiments are an evolutionary advance and improvementcompared to the apparatus illustrated in the aforementioned relatedapplications, and are quite unique and different from all otherconventional locking mechanisms used for other types of anterior lumbarcages.

A possible conventional device conceivably may include anterior placedlumbar implants with perforating screws. The conventional device mayinclude a horseshoe implant having a plurality of cylindrical holes withsmooth inner surfaces and comprise only one stop for the heads of thebone screws to be inserted into them. The placement of five cylindricalholes is oriented within the cage in a non-symmetric manner.

In comparison, the exemplary embodiments differ in many substantial waysfrom the conventional devices. For example, the exemplary embodimentsprovide a symmetric orientation of the screw holes, as well as a screwlocking mechanism. The exemplary embodiments also provide anangulation/trajectory (e.g., an approximate twenty five degreeangulation/trajectory) for preventing pull-out or back-out of the screwsthat would make placement of all screws in a manner which would lead tomaximum stability of the construct within the vertebral space, andobviate the need for external drill guides, and surgeon trajectoryangulation guess work.

In another possible conventional device, multiple embodiments of lumbarintervertebral implants may be presented which include one withinternally threaded bore holes, another embodiment with a front platemounted at the front surface of the implant, and another embodiment withthe front place displaceably configured to move vertically relative tothe implant. In addition, the disclosed preferred borehole axes may be35-55 degrees. These conventional devices may have four screwperforations that are not aligned four in a row. Two of the screw holesmay be laterally placed on the left, one on top of each other, the topone with a superior trajectory, and the bottom with an inferiortrajectory. Likewise, two perforations may be placed on the right, oneon top of each other, the top one with a superior trajectory and thebottom one with an inferior trajectory. The disclosed screw lockingmechanism may be a screw with an external thread matching the internalborehole thread, or spiral springs.

In comparison, the anterior lumbar construct of the exemplaryembodiments differs in many substantial ways from these conventionaldevices. The exemplary embodiments include a single cage construct withfour (4) internalized drill guides arranged horizontally in a row. Thelateral screw guides/screws are obliquely oriented with the respect totheir adjacent medial screw guides/screws. The middle two screws areoriented superiorly, and the lateral left and right screws are orientedinferiorly. This symmetric alignment of screws and orientations withinthe superior and inferior vertebral bodies (e.g., two middle superiorlyprojecting screws, and two laterally projecting inferior screws) makethe fixation to the superior and inferior vertebral bodies much moresymmetric and thus more stable preventing subsidence. In an exemplaryembodiment, the cage includes a screw guide having a predeterminedtrajectory (e.g., an approximate trajectory of 25 degrees or anotherangulation) that makes placement of all screws equally facile, moreamenable to multi-level placement, and diminishes the need for externaldrill guides. Furthermore, the exemplary screw locking mechanism, whichis press-fit to the cage, is unique and differs substantially from theconventional approach of matching screw/cage threads or spiral springs.

FIGS. 3A-3F illustrate three-dimensional views of an exemplaryembodiment of a posterior lumbar rectangular intervertebral cage/BDFTconstruct. In this embodiment, the cage 210 includes indentations 290 ontop of the cage 290 that are adjacent to the internal screw guides 270,280 (FIG. 3F). The indentations 290 contain press-fit leaf springs 220.The cage 210 also includes indentations 12 on both side surfaces of theconstruct for the prong placement of an implantation tool. The screws230, 240 perforate and orient in opposing superior and inferiordirections.

The cage 210 can include a cavity 250 for bone product placement. Thetop and bottom portions of the rectangular cage 210 are ellipticallycontoured to naturally fit into the bi-concave intervertebral disc space(FIG. 3C; side view). The top of cage 210 is a square with equal widthand length. The cage 210 includes built-in internalized screw/drillguides 270, 280 having a predetermined angled trajectory (e.g., havingan approximate 25 degree angulation), and their axes are not horizontal,but oblique one to the other and very close to each other. Each screwguide/screw 270, 280 occupies one corner of a square, obliquely orientedone to the other (FIG. 3A). This necessary to achieve proper screwpenetration in so narrow a posterior lumbar interspace. One of theguides is angled rostrally (superiorly) (e.g., guide 270) and the othercaudally (inferiorly) (e.g., guide 280). The intervertebral cages 210can be designed with internalized screw/drill guides 270, 280 withdifferent angles and/or different positions within the cage 210. Becausethe tunnel of the screw guide 270, 280 narrows, when the screw 230, 240is countersunk on top of the cage 210, the screw 230, 240 ispreliminarily locked, even in the absence of this locking mechanism. Theangle and size of the screws 230, 240 make them amenable to single ormulti-level placement. The screw guide exit tunnel 13 adjacent to thebone cavity 250 is illustrated in FIG. 3D. The superior and inferiorsurfaces or edges can include ridges or the like to facilitateintegration and fusion with superior and inferior vertebral bodies. Oneof these constructs is placed posteriorly into the intervertebral spaceon the left side, and the other on the right side.

The cage 210 includes a leaf spring screw locking mechanism 220 that canbe, for example, press-fit into the indentation 290 adjacent to theinternalized screw guides 270, 280 on top of the cage 210. The top ofthe cage 210 can have an indentation 290 to engage the spring leaflocking mechanism 220. The spring leaf locking mechanism 220 can bemanufactured from a variety of materials, such as titanium. When thescrews 230, 240 with ratcheted screw heads are turned, the first screwmember 230 and the second screw member 240 are locked in a finalposition by its final turn when the screw head is flush with the surfaceof the cage 210. The adjacent leaf spring 20 prevents screw back out orpull out by engaging and locking the space between the ratchet teeth(trough) of the screw head when the screws 230, 240 are in their finalresting positions. This engagement prevents any rotation of the screw230, 240 in the opposite direction.

The exemplary embodiment of this novel intervertebral cage 210 is anevolutionary advance and improvement compared to the apparatusillustrated in the aforementioned related applications. The novel cage210 also is quite unique and different from other conventional lockingmechanisms used for other known cervical and lumbar anterior orposterior plate screws. No other conventional posterior lumbarintervertebral cage BDFT/screw constructs are known.

FIGS. 4A-4F illustrate three-dimensional views of an exemplaryembodiment of a posterior lumbar elliptical intervertebral cage/BDFTconstruct. In this embodiment, indentations 290 on top of the cage 210are adjacent to the internal screw guides 270, 280 (FIG. 4F). Theindentations 290 can contain press-fit leaf springs, 220.

The cage 210 also can include indentations or slots 12 on both sidesurfaces of the cage 210 for insertion of a prong of an implantationtool (see example cage and tool in FIG. 5D; the cage 210 can engage thetool in a similar manner), and more particularly, that engage the distalmedial oriented male protuberance of a lateral griper prong of animplantation tool.

The screws 230, 240 perforate and orient in opposing superior andinferior directions. The cage 210 can include a cavity 250 for boneproduct placement. The entire body of this cage 210 can be elliptical asopposed to the top and bottom portions of the rectangular cage of theprevious embodiment 210, and can be contoured when viewed from the sideto naturally fit into the bi-concave intervertebral disc space (FIG.4C).

The cage 210 includes built-in internalized screw/drill guides 270, 280having a predetermined angled trajectory (e.g., having an approximate 25degree angulation), and their axes are not horizontal, but oblique oneto the other and very close to each other. Each screw guide/screwoccupies one corner of a square, obliquely oriented one to the other(FIG. 4A). This necessary to achieve proper screw penetration in sonarrow a posterior lumbar interspace. One of the guides is angledrostrally (superiorly) (e.g., guide 270) and the other caudally(inferiorly) (e.g., guide 280). The intervertebral cages 210 can bedesigned with internalized screw/drill guides 270, 280 with differentangles and/or different positions within the cage 210. Because thetunnel of the screw guide 270, 280 narrows, when the screw 230, 240 iscountersunk on top of the cage 210, the screw 230, 240 is preliminarilylocked, even in the absence of this locking mechanism. The angle andsize of the screws 230, 240 make them amenable to single or multi-levelplacement. The screw guide exit tunnel 13 adjacent to the bone cavity250 is illustrated in FIG. 4D. The superior and inferior surfaces oredges can include ridges or the like to facilitate integration andfusion with superior and inferior vertebral bodies. One of theseconstructs is placed posteriorly into the intervertebral space on theleft side, and the other on the right side.

The cage 210 includes a leaf spring screw locking mechanism 220 that canbe, for example, press-fit into the indentation 290 adjacent to theinternalized screw guides 270, 280 on top of the cage 210. The top ofthe cage 210 can have an indentation 290 to engage the spring leaflocking mechanism 220. The spring leaf locking mechanism 220 can bemanufactured from a variety of materials, such as titanium. When thescrews 230, 240 with ratcheted screw heads are turned, the first screwmember 230 and the second screw member 240 are locked in a finalposition by its final turn when the screw head is flush with the surfaceof the cage 210. The adjacent leaf spring 220 prevents screw back out orpull out by engaging and locking the space between the ratchet teeth(trough) of the screw head when the screws 230, 240 are in their finalresting positions. This engagement prevents any rotation of the screw inthe opposite direction.

The exemplary embodiment of this novel intervertebral cage 210 is anevolutionary advance and improvement compared to the apparatusillustrated in the aforementioned related applications. The novel cage210 also is quite unique and different from other conventional lockingmechanisms used for other known cervical and lumbar anterior orposterior plate screws. No other conventional posterior lumbarintervertebral cage BDFT/screw constructs are known.

2. Exemplary Surgical Method

Exemplary surgical steps for practicing one or more of the forgoingembodiments will now be described.

Anterior cervical spine placement of the intervertebral cage/BDFT screwconstruct 10 (FIG. 1) can be implanted via previously describedtechniques for anterior cervical discectomy and fusion. Some but not allof these techniques include, open, microscopic, closed endoscopic ortubular. Fluoroscopic or any other form of visualized guidance can beused for this procedure.

After the adequate induction of anesthesia the patient is placed in asupine position. An incision is made overlying the intended disc spaceor spaces, and the anterior spine is exposed. A discectomy is performedand the endplates exposed. The disc height is measured and an anteriorcervical intervertebral cage of the appropriate disc height, width anddepth is selected. The central cavity is packed with bone fusionmaterial, autologous bone graft, allograft, alone or in combination withany commercially available bone fusion promoting product. The cage 10 isthen inserted into the midline of the anterior disc space routinelyuntil it is flush or countersunk relative to the vertebral body aboveand below. The BDFT screws 30, 40 are then inserted into theinternalized rostrally (superiorly) and caudally (inferiorly) angledscrew guides 80, 90. A drill with or without a drill guide can be usedto prepare for screw placement. This is not absolutely necessary.Because the cage 10 has internalized screw guides 80, 90,self-drilling/self-tapping screws 30, 40 of the appropriately selectedlengths can be directly screwed into the vertebral bodies once placedinto the internalized drill-guided angled tunnels. The cage's screwguides 80, 90, which have internalized tunnels, direct the screws 30, 40into the superior and inferior vertebral bodies in the predeterminedangle of the internalized tunnels. There is no other angled trajectoryother than that which is built into the internalized screw guide/tunnelof the cage 10 that the screw 30, 40 can be oriented in. Hence, there isno absolute need for fluoroscopic guidance.

Once the surgeon is satisfied with the position and placement of thecage 10, the BDFT screws 30, 40 can then be locked into their finalpositions. When each of the BDFT screws 30, 40 with ratcheted screwheads are turned, they penetrate and engage the bone until they arelocked in a final position by its final turn when the screw head isflush with the surface of the cage 10. The adjacent leaf spring 20prevents screw back out or pull out by engaging and locking the spacebetween the ratchet teeth of the screw head (trough) when the screws 30,40 are in their final resting positions. This engagement because of thegeometric arrangement of the ratchet teeth and troughs prevents anyrotation of the screw 30, 40 in the opposite direction. Once the screw30, 40 is in this position it can no longer be backed out withoutdestroying the leaf spring mechanism 20. The surgeon has the option toverify the trajectory fluoroscopically by applying preliminarynon-ratcheted BDFT screws 30, 40 which lack ratchet teeth on their screwheads. Once the surgeon is confident of the screw trajectory verified byx-ray, the BDFT screws 30, 40 with screw head ratchet teeth can beinserted and locked in their final position. Because of the presence ofinternalized screw-guides 80, 90 within the cage 10, this step is notabsolutely necessary, but is an option available for the surgeon as adouble-check measure.

Anterior or anteriolateral placement of thoracic or lumbar spineintervertebral cage/BDFT screw constructs 110 (FIG. 2) can be implantedvia previously described surgical techniques for anterior lumbardiscectomy, and transthoracic, anterior-lateral thoracic discectomy.Some but not all of these techniques include, open, microscopic, closedendoscopic or tubular. Fluoroscopic or any other form of visualizedguidance can be used for this procedure.

After the adequate induction of anesthesia and after the anterior spineis exposed a discectomy is performed and the endplates exposed. The discheight is measured and an anterior lumbar (or thoracic) intervertebralcage of the appropriate disc height, width and depth is selected. Thecentral cavity 180 is packed with bone fusion material, autologous bonegraft, allograft, alone or in combination with any commerciallyavailable bone fusion promoting product. The cage 110 is then insertedinto the midline of the anterior disc space routinely until it is flushor countersunk relative to the vertebral body above and below. The fourBDFT screws 130, 140, 150, 160 with screw heads with ratchet teeth arethen inserted into the two middle internalized rostrally (superiorly)and two lateral, caudally (inferiorly) angled screw guides 190, 192. Adrill with or without a drill guide can be used to prepare for screwplacement. This is not absolutely necessary. Because the cage 110 hasinternalized screw guides 190, 192, self-drilling/self-tapping screws130, 140, 150, 160 of the appropriately selected lengths can be directlyscrewed into the vertebral bodies once placed into the internalizeddrill-guided angled tunnels. The cage's internalized guides 190, 192,which have internalized tunnels, direct the screws 130, 140, 150, 160into the superior and inferior vertebral bodies in the predeterminedangle of the internalized tunnels. There is no other angled trajectoryother than that which is built into the internalized screw guide/tunnelof the cage 110 that the screw 130, 140, 150, 160 can be oriented in.Hence there is no absolute need for fluoroscopic guidance.

Once the surgeon is satisfied with the position and placement of thecage 110, the BDFT screws 130, 140, 150, 160 can then be locked intotheir final positions. When each of the BDFT screws 130, 140, 150, 160with ratcheted screw heads are turned, the screws 130, 140, 150, 160penetrate and engage the bone until they are locked in a final positionby its final turn when the screw head is flush with the surface of thecage 110. The adjacent leaf spring 120 prevents screw back out or pullout by engaging and locking the space between the ratchet teeth of thescrew head (trough) when the screws 130, 140, 150, 160 are in theirfinal resting positions. This engagement prevents any rotation of thescrew 130, 140, 150, 160 in the opposite direction. Once the screw 130,140, 150, 160 is in this position it can no longer be backed out withoutdestroying the leaf spring mechanism 20. The surgeon has the option toverify the trajectory fluoroscopically by applying preliminarynon-ratcheted BDFT screws 130, 140, 150, 160 which lack ratchet teeth ontheir screw heads. Once the surgeon is confident of the screw trajectoryverified by x-ray, the BDFT screws 130, 140, 150, 160 with screw headratchet teeth can be inserted and locked in their final position.Because of the presence of internalized screw-guides 180, 190 within thecage 110, this step is not absolutely necessary, but is an optionavailable for the surgeon as a double-check measure.

Implantation of the posterior lumbar intervertebral cage/BDFT screwconstructs 110 (FIGS. 3 and 4) can be performed via previously describedposterior lumbar interbody fusion (PLIF) or posterior transforaminallumbar interbody fusion (TLIF) procedures. The procedures can beperformed open, microscopic, closed tubular or endoscopic techniques.Fluoroscopic guidance can be used with any of these procedures.

After the adequate induction of anesthesia, the patient is placed in theprone position. A midline incision is made for a PLIF procedure, and oneor two parallel paramedian incisions or a midline incision is made forthe TLIF procedure. For the PLIF procedure, a unilateral or bilateralfacet sparing hemi-laminotomy is created to introduce the posteriorlumbar construct into the disc space after a discectomy is performed andthe space adequately prepared.

For the TLIF procedure, after unilateral or bilateral dissection anddrilling of the inferior articulating surface and the medial superiorarticulating facet the far lateral disc space is entered and acircumferential discectomy is performed. The disc space is prepared andthe endplates exposed.

The disc height is measured and a posterior lumbar intervertebralcage/BDFT screw construct (FIGS. 3 and 4) of the appropriate discheight, width and depth is selected. The central cavity 250 is packedwith bone fusion material, autologous bone graft, allograft, alone or incombination with any commercially available bone fusion promotingproduct. Then one construct 210 is placed on either right or left sides,or one construct each is placed into left and right sides. Theconstructs are inserted such they are flush or countersunk relative tothe superior and inferior vertebral bodies. In addition to the centralcavities 250 that are packed with bone product, the intervertebral spacein between the constructs can also be packed with bone product forfusion.

The BDFT screws 230, 240 are then inserted into internalized rostrally(superiorly) and caudally (inferiorly) angled screw guides 270, 280. Adrill with or without a drill guide can be used to prepare for screwplacement. This is not absolutely necessary. Because the cage 210 hasinternalized screw guides 270, 280, self-drilling/self-tapping screws230, 240 of the appropriately selected lengths can be directly screwedinto the vertebral bodies once placed into the internalized drill-guidedangled tunnels. The cage's internalized guides 270, 280, which haveinternalized tunnels, direct the screws 230, 240 into the superior andinferior vertebral bodies in the predetermined angle of the internalizedtunnels. There is no other angled trajectory other than that which isbuilt into the internalized screw guide/tunnel 270, 280 of the cage 210that the screw 230, 240 can be oriented in. Hence, unlike posteriorplacement of pedicle screws 230, 240 there is no absolute need forfluoroscopic or expensive and cumbersome, frameless stereotactic CTguidance.

Once the surgeon is satisfied with the position and placement of thecage 210, the BDFT screws 230, 240 can then be locked into their finalpositions. When each of the BDFT screws 230, 240 with ratcheted screwheads are turned, they penetrate and engage the bone until they arelocked in a final position by its final turn when the screw head isflush with the surface of the cage 210. The adjacent leaf spring 220prevents screw back out or pull out by engaging and locking the spacebetween the ratchet teeth of the screw head (trough) when the screws230, 240 are in their final resting positions. This engagement preventsany rotation of the screw 230, 240 in the opposite direction. Once thescrew 230, 240 is in this position it can no longer be backed outwithout destroying/disrupting the leaf spring mechanism 220. The surgeonhas the option to verify the trajectory fluoroscopically by applyingpreliminary non-ratcheted BDFT screws 230, 240 which lack ratchet teethon their screw heads. Once the surgeon is confident of the screwtrajectory verified by x-ray, the BDFT screws 230, 240 with screw headratchet teeth can be inserted and locked in their final position.Because of the presence of internalized screw-guides 270, 280 within thecage 210, this step is not absolutely necessary, but is an optionavailable for the surgeon as a double-check measure.

The present inventions may provide effective and safe techniques thatovercome the problems associated with current transpedicular basedcervical, thoracic and lumbar fusion technology, as well as anteriorcervical, thoracic and lumbar plating technology, and for manydegenerative stable and unstable spinal diseases. These inventions couldreplace much pedicle screw, and anterior plating based instrumentationin many but not all degenerative spine conditions.

The speed and simplicity of placement of anterior and posterior lumbarintervertebral cage/BDFT screw constructs, and placement of anteriorcervical cage/BDFT screw constructs far exceeds that of current pediclescrew and anterior spinal plating technology. Furthermore, these deviceshave markedly significantly decreased risk of misguided screw placementand hence decreased risk of neurovascular injury, and blood loss. Thelumbar and cervical intervertebral cage/BDFT screw constructs all wouldhave decreased recovery time, and more rapid return to work timecompared to pedicle screw, and plating technology. These devices withgreat probability lead to similar if not equal fusion rates, withsubstantially less morbidity, and hence, overall, make them a majoradvance in the evolution of spinal instrumented technology leading toadvances in the compassionate care of the spinal patient.

FIGS. 5A, 5B, 5C(i), and 5C(ii) illustrate an exemplary embodiment ofexemplary cage 200. These features are shown for example purposes, arenot limited to the cage 200, and can be incorporated into any cageaccording to any of the embodiments described herein. As shown in FIGS.5C(i) and 5C(ii), the screw guides can be positioned within four (4)quadrants I, II, III, IV.

For example, the intervertebral cage can include a wall having an entryopening of the first integral screw guide and an entry opening of thesecond integral screw guide, wherein the wall of the cage can includefour quadrants delineated by a first axis and a second axis each lyingin a plane of the wall, and the first axis is at a right angle withrespect to the second axis, wherein the four quadrants include a firstquadrant, a second quadrant, a third quadrant, and a fourth quadrant,wherein the first quadrant and the fourth quadrant are opposed to thesecond quadrant and the third quadrant with respect to the first axis,and the first quadrant and the second quadrant are opposed to the thirdquadrant and the fourth quadrant with respect to the second axis,wherein the first quadrant is diagonally opposed to the third quadrant,and the second quadrant is diagonally opposed to the fourth quadrant,and wherein one of a majority of an area of the entry opening of thefirst integral screw guide is in the first quadrant and a majority of anarea of the entry opening of the second integral screw guide is in thethird quadrant; and the majority of the area of the entry opening of thefirst integral screw guide is in the second quadrant and the majority ofthe area of the entry opening of the second integral screw guide is inthe fourth quadrant.

In an embodiment, the intervertebral cage can include a wall having anentry opening of the first integral screw guide and an entry opening ofthe second integral screw guide, wherein the wall has four quadrantsdelineated by a first axis and a second axis each lying in a plane ofthe wall, and the first axis is at a right angle with respect to thesecond axis, wherein the four quadrants include a first quadrant, asecond quadrant, a third quadrant, and a fourth quadrant, wherein thefirst quadrant and the fourth quadrant are opposed to the secondquadrant and the third quadrant with respect to the first axis, and thefirst quadrant and the second quadrant are opposed to the third quadrantand the fourth quadrant with respect to the second axis, wherein thefirst quadrant is diagonally opposed to the third quadrant, and thesecond quadrant is diagonally opposed to the fourth quadrant, andwherein one of a center of the entry opening of the first integral screwguide is in the first quadrant and a center of the entry opening of thesecond integral screw guide is in the third quadrant; and the center ofthe entry opening of the first integral screw guide is in the secondquadrant and the center of the entry opening of the second integralscrew guide is in the fourth quadrant.

FIG. 5D illustrates an embodiment of an external drill/screw guide-boxexpander which assists in screw trajectory of the exemplary cage 200.The cage 200 can be a cage according to any of the embodiments describedherein, or an expanding cage, in which case an expanding Allen keycomponent can be used. The device can include, for example, an Allen key501 (e.g., for an expandable cage), a spring 502, a handle 503, agripper 504 having a gripper prong 506, which alternatively may includea male protuberance (e.g., a medially oriented mal protuberant extensionfor insertion into the lateral cage slot 12), and a screw guide 505.

FIG. 5E illustrates a superior oblique view of the screw guidedemonstrating insertions or grooves 509 for gripper prong 506 of thegripper 504 in FIG. 5D, built-in trajectory guides 511, 512 forinsertions of screws, and an opening 514 for an Allen key, in instancesin which an expandable cage is being used. In an embodiment, the Allenkey may not be present when a non-adjustable cage is being used. Inanother embodiment, the Allen key may be present even when an adjustablecage is being used, such that the tool is universal to various types ofcages.

The gripper 504 can include gripper prongs (e.g., medially oriented maleprotuberant extensions) 506 which insert into grooves 509 of the screwguide 505 and lateral slots (e.g., 12) of a cage, thereby perfectlyaligning them.

Hence, according to the exemplary embodiments, a cage can be providedthat has internal screw guides which have no gaps, and furthermore aninsertion tool can be provided that has an external screw guide thatfurther precisely guides the screws through the external tool screwguide, then into the internal implant screw guide guaranteeing theprecise predetermined angulation of the screws. The combination theinternal and external screw guides can create a long tunnel for a screwto enable a predetermined trajectory.

It is noted that the same trajectory can be provided by only with theinternal box screw guides; however, one of ordinary skill will recognizethat having the external screw guides as part of the tool furthermaintains the precise angle trajectory. The screw guide positions withinthe four (4) quadrants I, II, III, IV conform to the screw guidepositions within the four (4) quadrants I, II, III, IV of the screw box.

With reference to the drawings, it will be understood that an embodimentof the indentations or recesses for the screw holes in any of theexemplary cages can be configured such that the screw heads will restentirely within a peripheral side of a surface of the top portion of thecage (i.e., top surface). In this embodiment, the direction of the screwtunnel is from an anterior surface to a posterior of the top surface ofthe cage (i.e., the non-adjacent side).

In another embodiment, the indentations or recesses for the screw holescan be configured such that the screw heads will rest entirely withinthe peripheral side of the top surface of the cage. In this embodiment,the screw hole guide passes through the anterior-posterior axis of thetop surface. The guides core circumference for the screw thread issurrounded by the lateral wall masses, and surrounded by mass from thefront and rear surfaces (i.e., walls) of the cage.

In yet another embodiment, the indentations or recesses for the screwholes can be configured such that a recess for the screw holes areentirely within the peripheral side of the top surface of the box. Inthis embodiment, there is a through-hole for a screw which iscounter-bored to keep the screw head within an outer surface boundary ofthe cage and in a direction to prevent the screw from avoiding the frontor rear surfaces of the cage.

In yet another embodiment, the indentations or recesses for the screwholes can be configured such that a recess for the screw holes isentirely within the peripheral side of the front wall of the cage Inthis embodiment, the tunnel for the screws is such that when the screwfirst enters, the screw will be surrounded by mass from the lateralsides and mass from the upper and lower sides of the wall. The screwwill exit at the posterior end of the peripheral wall.

With reference to the drawings, it will be understood that an embodimentof the indentations or recesses for the screw holes can be configuredsuch that a position of the screws is suitable for posterior lumbarscrew holes.

For example, in an embodiment, the screw holes can be diagonal to eachother along a transversal line. The transversal line can be defined asthe line that would diagonally intersect and bypass the space betweenthe recess for the screw holes.

In another embodiment, the screw holes can be diagonally opposed and lieon a congruent angle to each other from the intersecting transversalline.

In another embodiment, the recess for the screw holes can be diagonaland perpendicular to each other within the outer plane.

In another embodiment, the recess for the screw holes can be diagonaland symmetrically constrained within the outer wall of the cage.

While the foregoing disclosure shows illustrative embodiments of theinvention, it should be noted that various changes and modificationscould be made herein without departing from the scope of the inventionas defined by the appended claims. The functions, steps and/or actionsof the method claims in accordance with the embodiments of the inventiondescribed herein need not be performed in any particular order.Furthermore, although elements of the invention may be described orclaimed in the singular, the plural is contemplated unless limitation tothe singular is explicitly stated.

What is claimed is:
 1. A universal, intervertebral combination bonefusion spacer and self-drilling screw apparatus for insertion into adisc space between a first vertebral body and a second vertebral bodyand fusion of the first vertebral body to the second vertebral body viabiological bone fusion and screw fusion, the apparatus comprising: anintervertebral cage including: a first integral screw guide having afirst predetermined angle; and a second integral screw guide having asecond predetermined angle; a first screw member disposed in the firstintegral screw guide at the first predetermined angle and at leastpartially within the intervertebral cage; a second screw member disposedin the second integral screw guide at the second predetermined angle andat least partially within the intervertebral cage; and a screw lockingmechanism that secures at least one of the first screw member and thesecond screw member in one of the first internal screw guide and thesecond internal screw guide, wherein each of the first internal screwguide and the second internal screw guide is angled to orient the firstscrew member and the second screw bi-directionally in oppositedirections, wherein the first screw member includes a screw head and athreaded body, wherein the second screw member includes a screw head anda threaded body.
 2. The apparatus of claim 1, wherein the screw lockingmechanism secures the first screw member in the first internal screwguide and the second screw member in the second internal screw guide. 3.The apparatus of claim 1, wherein the first screw member includes ascrew head, a tapered end, and a threaded body; wherein the second screwmember includes a screw head, a tapered end, and a threaded body.
 4. Theapparatus of claim 1, wherein each of the first integral screw guide andthe second integral screw guide includes a descending narrowing screwguide that narrows in a direction extending from top to bottom.
 5. Theapparatus of claim 4, wherein the first screw member and the secondscrew member are disposed in each descending narrowing screw guide andcountersunk on top of the intervertebral cage such that each descendingnarrowing screw guide hugs each respective one of the first screw memberand the second screw member to provide a secondary locking mechanism foreach of the first screw member and the second screw member that isindependent of the screw locking mechanism.
 6. The apparatus of claim 1,wherein the screw locking mechanism comprises: a first indentationformed in the intervertebral cage adjacent to at least one of the firstintegral screw guide and the second integral screw guide; and a firstleaf spring that engages the first indentation and prevents at least oneof the first screw member and the second screw from pulling-out of theat least one of the first integral screw guide and the second integralscrew guide.
 7. The apparatus of claim 6, wherein the first leaf springis a press-fit leaf spring that is press fit into the first indentation.8. The apparatus of claim 6, wherein the first leaf spring is press-fitinto a surface of the intervertebral cage.
 9. The apparatus of claim 6,wherein the first leaf spring is configured to permit the at least oneof the first screw member and the second screw to rotate in apenetrating direction and prevent the at least one of the first screwmember and the second screw to rotate in an extracting direction, theextracting direction being opposite to the penetrating direction. 10.The apparatus of claim 6, wherein the screw head of the at least one ofthe first screw member and the second screw includes ratchet teeth on anexternal surface of the screw head, and wherein the first leaf springengages the ratchet teeth to permit the at least one of the first screwmember and the second screw to rotate in a penetrating direction andprevent the at least one of the first screw member and the second screwfrom rotating in an extracting direction, the extracting direction beingopposite to the penetrating direction.
 11. The apparatus of claim 6,wherein the intervertebral cage includes a second indentation formed inthe intervertebral cage adjacent to another of the first integral screwguide and the second integral screw guide; and a second leaf spring thatengages the second indentation and prevents the another of the firstscrew member and the second screw from pulling-out of the at least oneof the first integral screw guide and the second integral screw guide.12. The apparatus of claim 11, wherein the screw heads of each of thefirst screw member and the second screw include ratchet teeth on anexternal surface of each of the screw heads, and wherein the first leafspring and the second leaf spring each engage the ratchet teeth of arespective screw head to permit each respective one of the first screwmember and the second screw to rotate in a penetrating direction andprevent each respective one of the first screw member and the secondscrew from rotating in an extracting direction, the extracting directionbeing opposite to the penetrating direction.
 13. The apparatus of claim6, wherein the first indentation is formed in a top surface of theintervertebral cage adjacent to the first integral screw guide.
 14. Theapparatus of claim 6, wherein the intervertebral cage includes: a thirdinternal screw guide; a fourth internal screw guide; a third screwmember having a screw head with ratchet teeth and disposed in the thirdinternal screw guide; and a fourth screw member having a screw head withratchet teeth and disposed in the fourth internal screw guide; a thirdleaf spring that prevents the third screw member from pulling out of thethird internal screw guide; and a fourth leaf spring that prevents thefourth screw member from pulling out of the fourth internal screw guide.15. A bi-directional fixating transvertebral (BDFT) screw/cageapparatus, comprising: an intervertebral cage for maintaining discheight, the intervertebral cage including a first internal screw guide,a second internal screw guide, a third internal screw guide, and afourth internal screw guide, each having a predetermined angledtrajectory; a first screw member, a second screw member, a first screwmember, and a fourth screw member, each having a screw head with ratchetteeth, a tapered end and a threaded body disposed within theintervertebral cage; a leaf spring screw locking mechanism that preventsthe first screw member, the second screw member, the third screw member,and the fourth screw from pulling-out of the first internal screw guide,the second internal screw guide, the third internal screw guide, and/orthe fourth internal screw guide respectively; and a cage indentationadjacent to the four screw guides which contain press-fit leaf springscrew locking mechanisms.
 16. The apparatus of claim 15, wherein cageindentations are adjacent to the four screw guides.
 17. An integralintervertebral cage spacer and bi-directional fixating/fusiontransvertebral body screw apparatus, comprising: an intervertebral cageincluding a plurality of internal angled screw guides; a plurality ofscrew members having a screw head with ratchet teeth, a tapered end anda threaded body disposed within the plurality of internal angled screwguides of the intervertebral cage; and a screw locking mechanism thatprevents the plurality of screw members from pulling out of theplurality of internal angled screw guides, an indentation adjacent tothe screw guides which contains a press fit leaf spring that functionsas a screw locking mechanism, wherein the plurality of internal angledscrew guides orients a first screw member of the plurality of screwmembers rostrally (superiorly) and a second screw member of theplurality of screw members caudally (inferiorly).
 18. A method ofinserting a bi-directional fixating transvertebral (BDFT) screw/cageapparatus between a first vertebral body and a second vertebral body,the method comprising: measuring a dimension of a disc space between thefirst vertebral body and the second vertebral body; determining that thedisc space is a posterior lumbar disc space, an anterior lumbar discspace, or an anterior cervical disc space; selecting an intervertebralcage based on the measured dimension of the disc space and based on thedetermination of the disc space being the posterior lumbar disc space,the anterior lumbar disc space, or the anterior cervical disc space;inserting the selected intervertebral cage into a midline of the discspace until the selected intervertebral cage is flush or countersunkrelative to the first vertebral body and the second vertebral body;inserting a first screw member into a first internal screw guide of theselected intervertebral cage; inserting a second screw member into asecond internal screw guide of the selected intervertebral cage;screwing the first screw member and the second screw member into thefirst vertebral body and the second vertebral body respectively;confirming a position and placement of the intervertebral cage relativeto the first vertebral body and the second vertebral body; and lockingthe first screw member and the second screw member in a final positionby its final turn when the screw head is flush with the surface of thecage, wherein the adjacent leaf spring prevents screw back out or pullout by engaging and locking the space between the ratchet teeth of thescrew head when the screws are in their final resting positions, suchthat this engagement prevents any rotation of the screw in the oppositedirection, and wherein when the screw is in this position it can nolonger be backed out without disrupting/destroying the leaf springmechanism.
 19. A screw locking mechanism comprising screws with ratchetscrew heads, and adjacent leaf springs, which can also be used to securescrews to plates or any other devices which require a screw lockingmechanism to prevent screw back out.
 20. The apparatus of claim 1,wherein each of the first internal screw guide and the second internalscrew guide has a 25 degree angulation.
 21. The apparatus of claim 1,wherein the first screw member is oriented rostrally (superiorly) andthe second screw member is oriented caudally (inferiorly).
 22. Theapparatus of claim 1, wherein the first internal screw guide and thesecond internal screw guide are aligned along a longitudinal axis of theintervertebral cage.
 23. The apparatus of claim 1, wherein the firstinternal screw guide and the second internal screw guide aresymmetrically disposed on each side of a center point of theintervertebral cage along a longitudinal axis of the intervertebralcage.
 24. The apparatus of claim 1, wherein each of the first internalscrew guide and the second internal screw guide includes a tunnel thatpermits only a predetermined angled trajectory of the first screw memberand the second screw member.
 25. The apparatus of claim 1, wherein apredetermined angled trajectory of the first internal screw guide isdifferent than a predetermined angled trajectory of the second internalscrew guide.
 26. The apparatus of claim 1, wherein each of the firstinternal screw guide and the second internal screw guide includes atunnel that permits only a 25 degree angulation of the first screwmember and the second screw member.
 27. The apparatus of claim 1,wherein the first screw member is a self-tapping and self-drilling screwmember having a tapered end and a threaded body, and wherein the secondscrew member is a self-tapping and self-drilling screw member having atapered end and a threaded body.
 28. The apparatus of claim 1, furthercomprising: a bone graft cavity for receiving bone packing material forbone fusion between the first vertebral body and the second vertebralbody.
 29. The apparatus of claim 28, wherein the bone graft cavityextends through the intervertebral cage for receiving bone packingmaterial for receiving bone packing material for bone fusion between thefirst vertebral body and the second vertebral body and across theintervertebral space.
 30. The apparatus of claim 1, further comprising:a plurality of bone graft cavities extending through the intervertebralcage for receiving bone packing material for bone fusion between thefirst vertebral body and the second vertebral body and across theintervertebral space.
 31. The apparatus of claim 1, wherein a surface ofeach longitudinal end of the intervertebral cage includes a tool matingfeature formed adjacent to an edge of an upper surface of theintervertebral cage for receiving a distal end of a prong of animplantation tool.
 32. The apparatus of claim 31, wherein the toolmating feature includes one of a slot and an indentation formed adjacentto the edge of the upper surface of the intervertebral cage forreceiving the distal end of the prong of the implantation tool.
 33. Theapparatus of claim 1, wherein the intervertebral cage includes an exitfor one of the first integral screw guide and the second integral screwguide, the exit being adjacent to or formed in an edge of the bone graftcavity.
 34. The apparatus of claim 33, wherein the exit is ahemi-circular indentation on the edge of the bone graft cavity.
 35. Theapparatus of claim 1, wherein a surface of each longitudinal end of theintervertebral cage includes an edge having an arcuate contour.
 36. Theapparatus of claim 1, wherein the intervertebral cage is an arcuatelycontoured cervical intervertebral cage adapted to fit into a bi-concavecervical disc space.
 37. The apparatus of claim 1, wherein theintervertebral cage is an arcuately contoured lumbar intervertebral cageadapted to fit into a bi-concave lumbar disc space.
 38. The apparatus ofclaim 1, wherein the intervertebral cage is an arcuately contouredposterior lumbar intervertebral cage adapted to fit into a bi-concavelumbar disc space.
 39. The apparatus of claim 1, wherein theintervertebral cage is configured for one of posterior lumbarintervertebral placement, anterior lumbar intervertebral placement,anterio-lateral thoracic intervertebral placement, and anterior cervicalintervertebral placement.
 40. The apparatus of claim 1, wherein theintervertebral cage includes a side having a plurality of ridges. 41.The apparatus of claim 40, wherein the plurality of ridges are disposedon at least one of a superior surface and an inferior surface of theintervertebral cage.
 42. The apparatus of claim 1, wherein a wall of theintervertebral cage having the first integral screw guide and the secondintegral screw guide has a thickness that is greater than a thickness ofsidewalls and longitudinal ends of the intervertebral cage.
 43. Theapparatus of claim 1, wherein a wall of the intervertebral cage havingthe first integral screw guide and the second integral screw guide has aheight that is greater than a height of sidewalls and longitudinal endsof the intervertebral cage.
 44. The apparatus of claim 1, wherein aheight and width of sidewalls and longitudinal ends of theintervertebral cage are tapered in a direction extending away from awall of the intervertebral cage having the first integral screw guideand the second integral screw guide.
 45. The apparatus of claim 1,wherein a wall of the intervertebral cage having the first integralscrew guide and the second integral screw guide is a parallel to anopposing wall, and wherein a length of the wall is greater than a lengthof the opposing wall.
 46. The apparatus of claim 1, wherein inner wallsof the bone graft cavity are convergent.
 47. The apparatus of claim 1,wherein an intersection of sidewalls and longitudinal ends of theintervertebral cage form a straight edge.
 48. The apparatus of claim 1,wherein an intersection of sidewalls and longitudinal ends of theintervertebral cage form an arcuate edge.
 49. The apparatus of claim 1,wherein the first integral screw guide and the second integral screwguide are adjacent to each other and at an angulation with respect to awall having the first integral screw guide and the second integral screwguide.
 50. The apparatus of claim 49, wherein a first angulation of thefirst integral screw guide is opposed to a second angulation of thesecond integral screw guide.
 51. The apparatus of claim 1, wherein thefirst integral screw guide and the second integral screw guide areadjacent to each other along a longitudinal extent of a wall having thefirst integral screw guide and the second integral screw guide, andwherein the first integral screw guide and the second integral screwguide are offset in opposite directions with respect to a center line ofthe longitudinal extent.
 52. The apparatus of claim 51, wherein a partof the first integral screw guide overlaps a part of the second integralscrew guide along the longitudinal extent of the wall having the firstintegral screw guide and the second integral screw guide.
 53. Theapparatus of claim 51, wherein the first integral screw guide and thesecond integral screw guide are at an angulation with respect to thewall having the first integral screw guide and the second integral screwguide.
 54. The apparatus of claim 53, wherein a first angulation of thefirst integral screw guide extends in a first direction from the wallhaving the first integral screw guide and the second integral screwguide toward a first side of the intervertebral cage, wherein a secondangulation of the second integral screw guide extends in a seconddirection from the wall having the first integral screw guide and thesecond integral screw guide toward a second side of the intervertebralcage, and wherein the first side is opposed to the second side.
 55. Theapparatus of claim 1, wherein the first integral screw guide and thesecond integral screw guide are at an angulation with respect to a wallhaving the first integral screw guide and the second integral screwguide.
 56. The apparatus of claim 1, wherein the first integral screwguide and the second integral screw guide diverge from each other. 57.The apparatus of claim 1, wherein the first integral screw guide and thesecond integral screw guide diverge from each other and are at anangulation with respect to a wall having the first integral screw guideand the second integral screw guide.
 58. The apparatus of claim 1,wherein the intervertebral cage further comprises: a third integralscrew guide; a fourth integral screw guide; and wherein the apparatusfurther comprises: a third screw member disposed in the third integralscrew guide and at least partially within the intervertebral cage; and afourth screw member disposed in the fourth integral screw guide and atleast partially within the intervertebral cage.
 59. The apparatus ofclaim 58, wherein the first screw member and the fourth screw member areoriented rostrally (superiorly) and the second screw member and thethird screw member are oriented caudally (inferiorly).
 60. The apparatusof claim 59, wherein the second screw member and the third screw memberare disposed between the first screw member and the fourth screw memberalong a longitudinal length of the intervertebral cage.
 61. Theapparatus of claim 58, wherein each of the first internal screw guide,the second internal screw guide, the third internal screw guide, and thefourth internal screw guide has a 25 degree angulation.
 62. Theapparatus of claim 58, wherein the first internal screw guide and thefourth internal screw guide are disposed adjacent to longitudinal endsof the intervertebral cage and the second internal screw guide and thethird internal screw guide are disposed between the first internal screwguide and the fourth internal screw guide, and wherein the firstinternal screw guide, the second internal screw guide, the thirdinternal screw guide, and the fourth internal screw guide angled toorient the first screw member and the fourth screw member in oppositedirections from the second screw member and the third screw member. 63.The apparatus of claim 58, wherein the first internal screw guide, thesecond internal screw guide, the third internal screw guide, and/or thefourth internal screw guide are aligned along a longitudinal axis of theintervertebral cage.
 64. The apparatus of claim 58, wherein the firstinternal screw guide, the second internal screw guide, the thirdinternal screw guide, and the fourth internal screw guide aresymmetrically disposed on each side of a center point of theintervertebral cage along a longitudinal axis of the intervertebralcage.
 65. The apparatus of claim 58, wherein the second screw member andthe third screw member are disposed between the first screw member andthe fourth screw member along a longitudinal axis of the intervertebralcage.
 66. The apparatus of claim 58, where the intervertebral cageincludes a screw insert for securing a second universal, intervertebralcombination bone fusion spacer and self-drilling screw apparatus to theuniversal, intervertebral combination bone fusion spacer andself-drilling screw apparatus via a plate.
 67. The apparatus of claim58, wherein a wall of the intervertebral cage having the first integralscrew guide, the second integral screw guide, the third integral screwguide, and the fourth integral screw guide has a thickness that isgreater than a thickness of sidewalls and longitudinal ends of theintervertebral cage.
 68. The apparatus of claim 58, wherein a wall ofthe intervertebral cage having the first integral screw guide, thesecond integral screw guide, the third integral screw guide, and thefourth integral screw guide has a height that is greater than a heightof sidewalls and longitudinal ends of the intervertebral cage.
 69. Theapparatus of claim 58, wherein a height and width of sidewalls andlongitudinal ends of the intervertebral cage are tapered in a directionextending away from a wall of the intervertebral cage having the firstintegral screw guide, the second integral screw guide, the thirdintegral screw guide, and the fourth integral screw guide.
 70. Theapparatus of claim 58, wherein a wall of the intervertebral cage havingthe first integral screw guide, the second integral screw guide, thethird integral screw guide, and the fourth integral screw guide is aparallel to an opposing wall, and wherein a length of the wall isgreater than a length of the opposing wall.
 71. The apparatus of claim1, wherein the intervertebral cage includes a wall having an entryopening of the first integral screw guide and an entry opening of thesecond integral screw guide, wherein the wall has four quadrantsdelineated by a first axis and a second axis each lying in a plane ofthe wall, and the first axis is at a right angle with respect to thesecond axis, wherein the four quadrants include a first quadrant, asecond quadrant, a third quadrant, and a fourth quadrant, wherein thefirst quadrant and the fourth quadrant are opposed to the secondquadrant and the third quadrant with respect to the first axis, and thefirst quadrant and the second quadrant are opposed to the third quadrantand the fourth quadrant with respect to the second axis, wherein thefirst quadrant is diagonally opposed to the third quadrant, and thesecond quadrant is diagonally opposed to the fourth quadrant, andwherein one of: a majority of an area of the entry opening of the firstintegral screw guide is in the first quadrant and a majority of an areaof the entry opening of the second integral screw guide is in the thirdquadrant; and the majority of the area of the entry opening of the firstintegral screw guide is in the second quadrant and the majority of thearea of the entry opening of the second integral screw guide is in thefourth quadrant.
 72. The apparatus of claim 1, wherein theintervertebral cage includes a wall having an entry opening of the firstintegral screw guide and an entry opening of the second integral screwguide, wherein the wall has four quadrants delineated by a first axisand a second axis each lying in a plane of the wall, and the first axisis at a right angle with respect to the second axis, wherein the fourquadrants include a first quadrant, a second quadrant, a third quadrant,and a fourth quadrant, wherein the first quadrant and the fourthquadrant are opposed to the second quadrant and the third quadrant withrespect to the first axis, and the first quadrant and the secondquadrant are opposed to the third quadrant and the fourth quadrant withrespect to the second axis, wherein the first quadrant is diagonallyopposed to the third quadrant, and the second quadrant is diagonallyopposed to the fourth quadrant, and wherein one of: a center of theentry opening of the first integral screw guide is in the first quadrantand a center of the entry opening of the second integral screw guide isin the third quadrant; and the center of the entry opening of the firstintegral screw guide is in the second quadrant and the center of theentry opening of the second integral screw guide is in the fourthquadrant.
 73. The apparatus of claim 1, wherein the intervertebral cageincludes a wall having an entry opening of the first integral screwguide and an entry opening of the second integral screw guide, the wallincluding a first corner and a second corner, the first corner beingarranged at an opposite side of the wall and an opposite end of the wallwith respect to the second corner, wherein the first integral screwguide and the second integral screw guide are diagonally arranged alonga direction extending from the first corner of the wall to the secondcorner of the wall.
 74. The apparatus of claim 1, wherein theintervertebral cage includes a wall having an entry opening of the firstintegral screw guide and an entry opening of the second integral screwguide, the wall including a first corner and a second corner, the firstcorner being arranged at an opposite side of the wall and an oppositeend of the wall with respect to the second corner, wherein the firstintegral screw guide and the second integral screw guide are adjacent toeach other along a longitudinal extent of the wall and are diagonallyarranged along a direction extending from the first corner of the wallto the second corner of the wall.
 75. The apparatus of claim 1, whereinthe intervertebral cage includes a top wall having an entry opening ofthe first integral screw guide and an entry opening of the secondintegral screw guide, wherein the screw locking mechanism includes anindentation adjacent to at least one of the first integral screw guideand the second integral screw guide.
 76. The apparatus of claim 75,wherein the indentation is formed only in the top wall.
 77. Theapparatus of claim 1, wherein the intervertebral cage includes anadjacent wall to the top wall, and wherein the indentation is formed inthe top wall and the adjacent wall.
 78. The apparatus of claim 75,wherein the indentation is a triangular-shaped indentation.
 79. Theapparatus of claim 1, wherein the intervertebral cage includes an topwall having an entry opening of the first integral screw guide and anentry opening of the second integral screw guide, wherein the screwlocking mechanism includes an indentation adjacent to each of the firstintegral screw guide and the second integral screw guide.
 80. Theapparatus of claim 75, wherein the indentation is configured such thatone of the screw head of the first screw member and the screw head ofthe second screw member is disposed entirely within a peripheral side ofa surface of the top wall, and wherein one of the first integral screwguide and the second integral screw guide passes through ananterior-posterior axis of the top wall.
 81. The apparatus of claim 75,wherein the intervertebral cage is adapted to fit into a lumbar discspace, and wherein the first integral screw guide is disposed diagonallyto the second integral screw guide with respect to a transversal line ofthe top surface.
 82. The apparatus of claim 75, wherein theintervertebral cage is adapted to fit into a lumbar disc space, andwherein the first integral screw guide and the second integral screwguide are diagonally opposed and lie on a congruent angle to each otherfrom the intersecting transversal line.
 83. The apparatus of claim 75,wherein the intervertebral cage is adapted to fit into a lumbar discspace, and wherein indentations for each of the first integral screwguide and the second integral screw guide are diagonal and perpendicularto each other within an outer plane of the top surface.
 84. Theapparatus of claim 75, wherein the intervertebral cage is adapted to fitinto a lumbar disc space, and wherein indentations for each of the firstintegral screw guide and the second integral screw guide are diagonaland symmetrically constrained within an outer wall of the cage.
 85. Anintegral intervertebral cage spacer and bi-directional fixating/fusiontransvertebral body screw apparatus, comprising: an intervertebral cageincluding a plurality of internal angled screw guides; a plurality ofscrew members having a screw head and a threaded body disposed withinthe plurality of internal angled screw guides of the intervertebralcage; and screw locking means for securing at least one of the pluralityof screw members in the plurality of internal angled screw guides.
 86. Amethod of inserting a bi-directional fixating transvertebral (BDFT)screw/cage apparatus between a first vertebral body and a secondvertebral body, the method comprising: measuring a dimension of a discspace between the first vertebral body and the second vertebral body;determining that the disc space is a posterior lumbar disc space, ananterior lumbar disc space, or an anterior cervical disc space;selecting an intervertebral cage based on the measured dimension of thedisc space and based on the determination of the disc space being theposterior lumbar disc space, the anterior lumbar disc space, or theanterior cervical disc space; inserting the selected intervertebral cageinto a midline of the disc space until the selected intervertebral cageis flush or countersunk relative to the first vertebral body and thesecond vertebral body; inserting a first screw member into a firstinternal screw guide of the selected intervertebral cage; inserting asecond screw member into a second internal screw guide of the selectedintervertebral cage; screwing the first screw member and the secondscrew member into the first vertebral body and the second vertebral bodyrespectively; confirming a position and placement of the intervertebralcage relative to the first vertebral body and the second vertebral body;and locking the first screw member and the second screw member in afinal position by embedding a portion of the screw head of the firstscrew member and the second screw member into a screw locking mechanismof the selected intervertebral cage.
 87. A universal, intervertebralcombination bone fusion spacer and self-drilling screw apparatus forinsertion into a disc space between a first vertebral body and a secondvertebral body and fusion of the first vertebral body to the secondvertebral body via biological bone fusion and screw fusion, theapparatus comprising: an intervertebral cage including: a first integralscrew guide having a first predetermined angle; a second integral screwguide having a second predetermined angle; and a bone graft cavity forreceiving bone packing material for bone fusion between the firstvertebral body and the second vertebral body; a first screw memberdisposed in the first integral screw guide at the first predeterminedangle and at least partially within the intervertebral cage; and asecond screw member disposed in the second integral screw guide at thesecond predetermined angle and at least partially within theintervertebral cage, a screw locking mechanism that secures at least oneof the first screw member and the second screw member in one of thefirst internal screw guide and the second internal screw guide, whereinthe first screw member is a self-tapping and self-drilling screw memberhaving a screw head, a tapered end, and a threaded body, wherein thesecond screw member is a self-tapping and self-drilling screw memberhaving a screw head, a tapered end, and a threaded body, wherein atleast one of the threaded body of the first screw member and thethreaded body of the second screw member engages the screw lockingmechanism, wherein the bone graft cavity extends through theintervertebral cage for receiving bone packing material for bone fusionbetween the first vertebral body and the second vertebral body andacross the intervertebral space, wherein each of the first internalscrew guide and the second internal screw guide is angled to orient thefirst screw member and the second screw bi-directionally in oppositedirections, wherein each of the first internal screw guide and thesecond internal screw guide includes a tunnel that permits only apredetermined angled trajectory of the first screw member and the secondscrew member, and the predetermined angled trajectory of the firstinternal screw guide is different than the predetermined angledtrajectory of the second internal screw guide, wherein theintervertebral cage includes an exit for one of the first integral screwguide and the second integral screw guide, the exit being adjacent to orformed in an edge of the bone graft cavity, wherein the intervertebralcage includes a side having a plurality of ridges, wherein a surface ofeach longitudinal end of the intervertebral cage includes a slot orindentation formed adjacent to an edge of an upper surface of theintervertebral cage for receiving a distal end of a prong of animplantation tool, wherein each of the first internal screw guide andthe second internal screw guide has a 25 degree angulation, wherein theintervertebral cage includes a wall having an entry opening of the firstintegral screw guide and an entry opening of the second integral screwguide, wherein the wall has four quadrants delineated by a first axisand a second axis each lying in a plane of the wall, and the first axisis at a right angle with respect to the second axis, wherein the fourquadrants include a first quadrant, a second quadrant, a third quadrant,and a fourth quadrant, wherein the first quadrant and the fourthquadrant are opposed to the second quadrant and the third quadrant withrespect to the first axis, and the first quadrant and the secondquadrant are opposed to the third quadrant and the fourth quadrant withrespect to the second axis, wherein the first quadrant is diagonallyopposed to the third quadrant, and the second quadrant is diagonallyopposed to the fourth quadrant, wherein one of: a majority of an area ofthe entry opening of the first integral screw guide is in the firstquadrant and a majority of an area of the entry opening of the secondintegral screw guide is in the third quadrant; and the majority of thearea of the entry opening of the first integral screw guide is in thesecond quadrant and the majority of the area of the entry opening of thesecond integral screw guide is in the fourth quadrant, and wherein thescrew locking mechanism comprises: a first indentation formed in theintervertebral cage adjacent to at least one of the first integral screwguide and the second integral screw guide; and a first leaf spring thatengages the first indentation and prevents at least one of the firstscrew member and the second screw from pulling-out of the at least oneof the first integral screw guide and the second integral screw guide.88. The apparatus of claim 1, wherein each of the first internal screwguide and the second internal screw guide has an angulation selectedfrom a range of 25 degrees to 40 degrees.